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Long-Term Services and Supports Skye N. Leedahl, Ph. D The University of Rhode Island Long-Term Services and Supports Skye N. Leedahl, Ph. D The University of Rhode Island Human Development and Family Studies

What are Long-Term Services and Supports (LTSS)? § LTSS are provided to people who What are Long-Term Services and Supports (LTSS)? § LTSS are provided to people who need assistance to perform routine daily activities over an extended period due to disability or chronic illness. § Goal of integrating supports and medical care to maintain health, improve functional capacity, enhance physical, social and emotional well-being, and maximize autonomy.

What are LTSS? § Includes a broad range of supportive services and supports provided What are LTSS? § Includes a broad range of supportive services and supports provided by professionals (formal care) as well as unpaid care provided by family and friends (informal care). § Can be provided in community-based or institutional settings.

Long-Term Care § LTSS is now the preferred term, but prior to that, most Long-Term Care § LTSS is now the preferred term, but prior to that, most referred to LTSS as “long-term care” § LTC continues to be used in private sector, in policy discussions, and by the general public § Definition is very similar to LTSS definition, focused mainly on formal care § Long-term care • A variety of ongoing health and social services provided for individuals who need assistance on a continuing basis because of physical or mental disability

How Many Receive LTSS? § Over 12 million Americans receive some kind of LTSS How Many Receive LTSS? § Over 12 million Americans receive some kind of LTSS (needing help with 1 or more ADLs or IADLs) • About 10. 9 million are community residents (1/2 are 65+) § Family members provide most assistance (over 90%) § Some live in supportive group homes (less than 10%) • Between 1. 5 -1. 8 million live in nursing homes (4/5 are 65+)

How Many Older Adults Receive LTSS? § About 20% (7. 7 million) older adults How Many Older Adults Receive LTSS? § About 20% (7. 7 million) older adults receive LTSS • Most live in the community and receive services/supports from family, friends, or community services • About 1. 1 million live in a nursing home

LTSS Options § Informal Caregivers (unpaid assistance) • Often family or friends § Formal LTSS Options § Informal Caregivers (unpaid assistance) • Often family or friends § Formal Care Services (paid assistance) Can include: • Home and Community-based Services (HCBS) • Assisted living • Continuing Care Retirement Communities (CCRCs) • Adult Day Care • Nursing homes

LTSS Financing § Medicaid is the primary payer for LTSS § Of total LTSS LTSS Financing § Medicaid is the primary payer for LTSS § Of total LTSS spending in 2013: • 51% Medicaid • 21% Other public funds • 19% Out-of-pocket • 8% Private insurance § Dual-eligible beneficiaries (receive Medicare and Medicaid) account for about 62% of Medicaid expenditures

How are LTSS Financed in the Community? § Only 13% (approximately 1. 6 million) How are LTSS Financed in the Community? § Only 13% (approximately 1. 6 million) of community residents receive formal services/paid help • Medicare and Medicaid are primary payers for about 1/3 of community residents (for all or most of charges) • About 1/4 of community residents pay out-ofpocket formal services (for all or most of the charges) • Rest is paid by some other source, often state or local programs

How are LTSS Financed in Nursing Homes? § Nursing homes cost about $3, 500 How are LTSS Financed in Nursing Homes? § Nursing homes cost about $3, 500 -$5, 000 per month: • Medicaid is the primary payer: § Paying about 2/3 of residents § Pays for greater proportions of residents as lengths of stay increase • Out-of-pocket payments and Medicare 2 nd and 3 rd most prominent payers: § About 1/5 of nursing home bills are paid for out-of -pocket § Medicare is a major payer during the first 3 months of nursing home stay, paying for about 17. 7% of residents

Current Policies & Programs that Influence LTSS § Medicaid § Medicare § PACE § Current Policies & Programs that Influence LTSS § Medicaid § Medicare § PACE § Money Follows the Person Program § Affordable Care Act § Older Americans Act § National Family Caregiver Program § Social Security

What is Medicaid? § Federally mandated, jointly (federal/state) funded, state by state controlled medical What is Medicaid? § Federally mandated, jointly (federal/state) funded, state by state controlled medical insurance for those below income level without insurance § Wide variance by state in eligibility and benefits

Who Qualifies for Medicaid? § Children § Pregnant Women § Parents § Older Adults Who Qualifies for Medicaid? § Children § Pregnant Women § Parents § Older Adults § Individuals with Disabilities * To qualify, individuals must meet income requirements * Other requirements depend on federal mandates and state options

Medicaid and State Variation § Each state develops a State Plan for their program Medicaid and State Variation § Each state develops a State Plan for their program and submits it to the federal government • Essentially 52 different programs: http: //medicaid. gov/medicaid-chip-programinformation/by-state. html § Large financial incentive for states: • Federal government pays 50 -80% of services • % depends on the state’s Federal Medical Assistance Percentage (FMAP), also known as the Federal Medicaid Matching Rate (which is based on state per capita income)

What are Medicaid State Plans? § Comprehensive written statement to federal government § Describe What are Medicaid State Plans? § Comprehensive written statement to federal government § Describe nature and scope of Medicaid program in the state § Contains assurances the program will be operated per the federal requirements § Are certain requirements that are mandatory § Are various options that states can include

What are Medicaid State Plans? § Can be amended • Takes about 90 days What are Medicaid State Plans? § Can be amended • Takes about 90 days to approve/disapprove amendment § States must have matching funds available before they get federal funds • Must be in the state plan to receive funds § Programs vary from state to state!

Medicaid Waivers and HCBS Options § 1915 (b): Managed Care waivers- allow states to Medicaid Waivers and HCBS Options § 1915 (b): Managed Care waivers- allow states to run managed care organizations § 1915 (c): HCBS waivers- provide LTC services in home § Combined 1915 (b) and 1915 (c) § 1115: Research and Demonstration Projects- test new or existing approaches to financing and delivery § 1915 (i) State Plan Home and Community-Based Services § 1915 (j) Self-Directed Personal Assistance Services Under State Plan § 1915 (k) Community First Choice

Medicaid Mandatory Services § Inpatient hospital § Outpatient hospital § Physician services § Nursing Medicaid Mandatory Services § Inpatient hospital § Outpatient hospital § Physician services § Nursing facilities for those over 21 years § Family planning § Lab/Xray § Home health § Rural health clinic services

Medicaid Mandatory Services § Federally qualified health center § Nurse practitioner § Nurse midwife Medicaid Mandatory Services § Federally qualified health center § Nurse practitioner § Nurse midwife § Early and periodic screening, Diagnostic and Treatment services (EPSDT) • Prevention services for those under 21 § Freestanding Birth Center services § Transportation to medical care § Tobacco cessation counseling for pregnant women

Medicaid Optional Services Includes: § Clinic services § Physical/occupational therapy § Prescription drugs § Medicaid Optional Services Includes: § Clinic services § Physical/occupational therapy § Prescription drugs § Dentures § Prosthetics § Optometrist/eyeglasses § Private duty nursing § Hospice

Medicaid Is Complicated Medicaid Is Complicated

Medicare § Federal Program § Social Insurance program • No means testing • Must Medicare § Federal Program § Social Insurance program • No means testing • Must have worked 40 quarters (person or spouse) § Who is entitled? • Age 65 and Older (about 80% of beneficiaries) • Under 65 with Certain Disabilities (about 20% of beneficiaries) • Those with End-Stage Renal Disease (about 1% of beneficiaries)

Medicare Benefits § Part A: Hospital Insurance § Part B: Medical Insurance § Part Medicare Benefits § Part A: Hospital Insurance § Part B: Medical Insurance § Part C: Medicare Advantage Plans § Part D: Prescription Drug Coverage

Medicare Choices Medicare Choices

Medicare Part A: Hospital Insurance § Inpatient Hospital Care § Skilled Nursing Facility Care Medicare Part A: Hospital Insurance § Inpatient Hospital Care § Skilled Nursing Facility Care (after discharge from hospital for a qualified stay up to 100 days) § Home Health Care (if qualify) § Hospice Care

Medicare Part B: Supplementary Medical Insurance § Doctor services § Outpatient medical and surgical Medicare Part B: Supplementary Medical Insurance § Doctor services § Outpatient medical and surgical services § Diagnostic tests (X-rays, MRIs) § Ambulance transportation § Durable medical equipment § Physical/occupational therapy § Dialysis § Rural health clinics § Other outpatient services § Early detection and preventive care benefits

Medicare Part C: Medicare Advantage Plans § Option to forego Original Medicare § Sign Medicare Part C: Medicare Advantage Plans § Option to forego Original Medicare § Sign up for private managed care plan Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), or fee-forservice plan § About 16% participation

Medicare Part D: Prescription Drugs § Offered through private prescription drug plans § All Medicare Part D: Prescription Drugs § Offered through private prescription drug plans § All plans must offer a standard level of coverage (range of drugs in each drug category) § Plans differ in what is covered and cost-sharing amounts. § Formulary • Drugs are categorized into § Tier 1 (lowest copayment, most generics) § Tier 2 (medium copayment, preferred brand name) § Tier 3 (high copayment, non-preferred brand name) § Specialty (unique, very high cost– e. g. , cancer) § Minimum Standard Coverage: • Monthly premium: ~$30

Medicare Does NOT Cover: § Long-Term Care Services except for rehabilitation services § Dentures Medicare Does NOT Cover: § Long-Term Care Services except for rehabilitation services § Dentures and most dental care § Cosmetic surgery § Acupuncture § Hearing aids § Eyeglasses and eye exams (unless have certain diagnoses) § Routine foot care services *can get supplementary plans (Medigap policies) to cover what Medicare does not

Program of All-Inclusive Care for the Elderly § Program of All-Inclusive Care for the Program of All-Inclusive Care for the Elderly § Program of All-Inclusive Care for the Elderly (PACE) § Program for people using Medicare, Medicaid, or both § Helps people meet health care needs in the community § Provides all care & services provided by Medicare and Medicaid, plus additional services § Funded through a monthly capitation payment from Medicare and Medicaid for each participant

Money Follows the Person (MFP) Program § Enables individuals utilizing Medicaid to transition from Money Follows the Person (MFP) Program § Enables individuals utilizing Medicaid to transition from nursing home to the community • Increases home and community base service availability • Eliminates Medicaid-usage barriers • Gives states’ Medicaid programs the ability to allow continuance of funding for HCBS services • Ensures quality services are provided in the community

The Patient Protection and Affordable Care Act (ACA) of 2010 (AKA Obama Care, Health The Patient Protection and Affordable Care Act (ACA) of 2010 (AKA Obama Care, Health Reform, Affordable Care Act) § How much do you know? • Watch this video: http: //kff. org/health-reform/video/youtoonsobamacare-video/ • Take this quiz: http: //kff. org/quiz/health-reform-quiz/

ACA Summary § Basic Idea: • All Americans are required to have health insurance ACA Summary § Basic Idea: • All Americans are required to have health insurance either through their employer or through insurance exchanges • Focuses on expanding coverage, controlling health care costs, and improve health care delivery system § Includes: • Industry regulation • Expansion of coverage • Mandates

ACA Medicare Changes ACA Medicare Changes

ACA Medicaid Changes ACA Medicaid Changes

Current Issues § Stay up-to-date on the latest issues and topics § Visit the Current Issues § Stay up-to-date on the latest issues and topics § Visit the Kaiser Foundation website for the latest on health reform statistics and issues: http: //kff. org/health-reform/

Older Americans Act (OAA) § OAA promotes the well-being of older individuals by providing Older Americans Act (OAA) § OAA promotes the well-being of older individuals by providing services and programs designed to help them live independently in their homes and communities § Administered by the Administration on Aging (Ao. A) • Office of Supportive and Caregiver Services • Office of Nutrition and Health Promotion Programs • Office of Elder Justice and Adult Protective Services • Office for American Indian, Alaska Natives, and Native Hawaiian Programs • Office of Long-term Care Ombudsman Programs • OAA and Aging Network

National Family Caregiver Program (NFCSP) § Provided through the Older Americans Act through grants National Family Caregiver Program (NFCSP) § Provided through the Older Americans Act through grants to states and territories § NFCSP funds a range of supports that assist family and informal caregivers care for their loved ones at home • Information about available services • Assistance in gaining access to services • Individual counseling, support groups, caregiver training • Respite care • Supplemental services

Social Security § Largest social insurance program § Monthly Income Benefits: Retirement, survivor’s, disability, Social Security § Largest social insurance program § Monthly Income Benefits: Retirement, survivor’s, disability, supplemental income, unemployment § Federal program

Programs within Social Security Includes: § Social Insurance • Old-Age, Survivors, and Disability Insurance Programs within Social Security Includes: § Social Insurance • Old-Age, Survivors, and Disability Insurance (OASDI) • Unemployment Insurance • Worker’s Compensation • Temporary Disability Insurance § Health Insurance and Health Services • Medicare • Medicaid § Assistance • Supplemental Security Income (SSI) • Temporary Assistance for Needy Families

Social Security Considerations § America’s safety net § Vehicle for promoting social justice § Social Security Considerations § America’s safety net § Vehicle for promoting social justice § Mechanism for allocating the costs and benefits of US citizenship § Quite controversial due to the costs imposed

Important Concepts and Services Relevant to LTSS § Activities of Daily Living (ADLs) and Important Concepts and Services Relevant to LTSS § Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) § Quality of care & quality of life § Informal caregivers § Home and community based services § Respite care § Adult day care § Assisted living § CCRCs § Nursing homes

ADLs and IADLs § ADLs: Ability to perform basic tasks • Bathing, dressing, toileting, ADLs and IADLs § ADLs: Ability to perform basic tasks • Bathing, dressing, toileting, transferring, continence, feeding § IADLs: Ability to perform more complex tasks • Ability to use the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for taking own medications, ability to handle finances § Assessments for ADLs and IADLs are often used to determine the need for LTSS and to help determine payments for services

Improving Quality § Goal of LTSS is to continuously improve quality § Quality measures Improving Quality § Goal of LTSS is to continuously improve quality § Quality measures refers to a wide variety of indicators related to personal and medical care • Can be assessed using measures of structure, processes, and outcomes of clinical care § Quality of life is a multi-dimensional concept related to an individual’s well-being • Related to emotional health, physical health, functional status, comfort and security, social function, and selfworth or agency

Informal Caregivers § Informal caregivers are the single largest source of LTSS in the Informal Caregivers § Informal caregivers are the single largest source of LTSS in the U. S. • This is only estimated to get larger as the Baby Boomers age. • Approximately 65. 7 million caregivers care for someone who is ill, disabled, or age • Services valued at $450 billion per year in 2009 • An estimated 66% are female

Home and Community-Based Services (HCBS) § Services provided through Medicaid or other state services Home and Community-Based Services (HCBS) § Services provided through Medicaid or other state services to individuals within their own home or community § Support choice and independence of older adults and adults with disabilities § Includes medical and non-medical services, including case management, homemaker, home health, personal care, adult day services, and respite care

Respite Care § Provides relief of caregiving responsibilities on a temporary or periodic basis Respite Care § Provides relief of caregiving responsibilities on a temporary or periodic basis § Services can include: adult day care, case managers, thorough assessment and counseling, in-home services, support groups, education, training materials

Adult Day Care § Adult day care centers provide a variety of services to Adult Day Care § Adult day care centers provide a variety of services to meet the needs of participants and family members § Is an alternative to nursing homes or assisted living § Older adults continue living in their home, but come to an adult day care center during the day

What Services Provided at Adult Day? § Services to address ADLs, nursing and other What Services Provided at Adult Day? § Services to address ADLs, nursing and other medical needs, psychosocial care, meals, and programs for caregiver well-being and support § Assistance with walking, toileting, meals, bathing, blood pressure monitoring, weight monitoring, medication management, diabetes monitoring

Assisted Living § According to the Assisted Living Coalition, the definition is: • A Assisted Living § According to the Assisted Living Coalition, the definition is: • A congregate residential setting that provides or coordinates personal services, 24 -hour supervision and assistance (scheduled and unscheduled), activities, and health related services. • Less government regulation and financing than nursing homes § Goals include: accommodate residents’ changing needs and preferences; maximize residents’ dignity, autonomy, and independence; and encourage family and community involvement

Key Assisted Living Statistics § Are currently 22, 000 assisted living residences (and similar Key Assisted Living Statistics § Are currently 22, 000 assisted living residences (and similar residential care communities) in the US housing more than 700, 000 residents § Most pay out-of-pocket for assisted living: • Average private-pay monthly rate for a private room with a private bath was about $3, 000, with average rents ranging from $2, 200 to $6, 199 • Some require security deposits, one-time community fees § Some availability of assisted living for Medicaid, Medicaid waiver, or state long-term care projects § 59% of AL residents eventually move into a nursing home, 33% will pass away at the AL, and rest will move home or to another location

Continuing Care Retirement Community (CCRC) § A residential community that older adults move to Continuing Care Retirement Community (CCRC) § A residential community that older adults move to for the rest of their lives. § Residents can move between levels of care (independent living, assisted living, skilled nursing) within one complex based on care needs § Approximately 2, 240 CCRCs in the US housing more than 745, 000 older adults

Nursing Homes (NHs) § Also referred to as: Skilled Nursing Facilities or Nursing Centers Nursing Homes (NHs) § Also referred to as: Skilled Nursing Facilities or Nursing Centers • Definition: Facilities with 3 or more beds staffed 24 hours per day by health professionals for residents who cannot remain in their own homes due to physical health problems, functional disabilities, and/or significant cognitive impairments § Only 4% of the population 65 and older live in NHs • 1. 5 million people total live in nursing homes

How is it Paid For? § At admission: • 42% private pay, 36. 4% How is it Paid For? § At admission: • 42% private pay, 36. 4% Medicare payments, 34. 8% Medicaid payments § All current residents (overlap due to having more than 1 source of payment) • 66% private funds, 12. 7% Medicare payments, 59% Medicaid § Why the difference between the two? Medicare limitations and spend down (spending personal funds until individuals qualify for Medicaid)

Key Resident Characteristics § 71. 2% Female § 82. 2% White, 14. 3% African Key Resident Characteristics § 71. 2% Female § 82. 2% White, 14. 3% African American, 5. 1% Latino/Hispanic, 1. 5% Asian/Pacific Islander, 0. 9% American Indian/Alaska Native § 51. 7% widowed, 18% married, 30% single § 60% graduated high school, 10% college graduates § 92. 8% have mobility impairments § 74. 8% cognitive impairments § 37. 2% sensory impairments

Highly-Regulated Industry § Skilled Nursing Facility (SNF): Medicare and Medicaidcertified § Nursing Facility (NF): Highly-Regulated Industry § Skilled Nursing Facility (SNF): Medicare and Medicaidcertified § Nursing Facility (NF): Medicaid-certified § If certified, must comply with federal requirements (42 CFR Sub Part 482, Subpart B) • States are tasked with certifying and enforcing requirements • Every 9 -15 months (or after a complaint), survey teams complete a survey and assess whether the facility is meeting approx. 189 federal regulations and any state regulations

Survey Process § Surveyors assess for quality indicators and can cite for deficiencies • Survey Process § Surveyors assess for quality indicators and can cite for deficiencies • For each deficiency, surveyors assign a level of severity and scope and issues enforcement remedies (e. g. , fines and/or directed plans of correction) • Over time and without improvement, NHs can lose the opportunity to receive government funding (which for many forces closure) § Survey information is publicly available through a website called Nursing Home Compare: https: //www. medicare. gov/nursinghomecompare/search. html • Consumers can utilize this to make informed decisions about moving to a nursing home § NHs focus great energy and resources in meeting regulations and avoiding deficiencies

Culture Change Movement § Goal is to “[go] beyond superficial changes to an inevitable Culture Change Movement § Goal is to “[go] beyond superficial changes to an inevitable reexamination of attitudes and behavior, and a slow and comprehensive set of fundamental reforms” (Rahman & Schnelle, 2008, p. 142) § Cultural change models are transforming facility practices to: • Empower frontline staff • Develop an environment in which residents’ quality of life improves through increased decision-making and potentialities for growth

Culture Change Movement § Physical structure of facilities redesigned to maximize the feeling of Culture Change Movement § Physical structure of facilities redesigned to maximize the feeling of a homelike environment • For example, small “neighborhoods” rather than large “nursing units” § Emphasis is on consistent care providers rather than rotating care providers

Kitchen Kitchen

Outdoor Activity Outdoor Activity

Floor Plan Floor Plan

Different Models § Eden Alternative: http: //www. edenalt. org/ • Person-directed approach to care, Different Models § Eden Alternative: http: //www. edenalt. org/ • Person-directed approach to care, growth, & wellbeing • Wellspring Model (now merged with Eden Alternative) § Focuses on teaching staff the best clinical and environmental changes (Kehoe & Van. Heesch, 2003) § Pioneer Network: https: //www. pioneernetwork. net/ • Promotes attitudinal change towards aging and older adults in enhancing quality of life

Green House Movement § Definition: • A self-contained home for 6 -10 people located Green House Movement § Definition: • A self-contained home for 6 -10 people located in clusters of 1 to 24 homes and designed to be similar to homes and apartments in the surrounding community • Licensed as skilled nursing homes and meet all federal and state requirements § Each person has a private room and bathroom that opens to a central living area, full kitchen, and dining room § Staffed by universal workers (called Shahbazim) and comprehensive clinical teams

Six Key Themes of Culture Change § Identified by an expert panel put together Six Key Themes of Culture Change § Identified by an expert panel put together by the Commonwealth Fund: • Care and all resident-related activities that are directed by the resident • A living environment that is designed to be a home rather than an institution • Close relationships existing between residents, family members, staff and community

Six Key Themes of Culture Change § Key themes continued: • Work organized to Six Key Themes of Culture Change § Key themes continued: • Work organized to support and empower all staff to respond to residents’ needs and desires • Management enabling collaborative and decentralized decision-making • Systematic processes that are comprehensive and measurement-based, and that are used for continuous quality improvement

Culture Change Benefits § A study conducted in 2007 by the Commonwealth Fund examined Culture Change Benefits § A study conducted in 2007 by the Commonwealth Fund examined the extent to which nursing homes (n = 1, 435) are adopting culture change principles and practicing resident-centered care § Results indicate that the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, facility occupancy rates, market competitive position, and operational costs.

Thank You! § Content prepared by: Skye N. Leedahl, Ph. D The University of Thank You! § Content prepared by: Skye N. Leedahl, Ph. D The University of Rhode Island Human Development and Family Studies